Many people trying to collect your health care data may be all too familiar with calling medical records departments, driving to a clinic to sign a release, and paying a fee for a stack of papers with lots of medical information they don't understand Health Services
But this spring, new federal rules went into effect that will allow patients to see clinical notes that doctors write, which advocates say will improve patients' knowledge of their own health.
Supporters of the open notes effort say they're optimistic this change will make a big difference because people will be able to click into their patient portal, like MyChart and other similar apps, and see what their doctors have written, instead of just a list of often confusing test results and other information. Psychotherapy counseling notes are exempt from the new requirements.
Catherine DsRoches, executive director of OpenNotes, a research group that promotes the sharing of clinical notes with patients, calls this a "new world" where shared notes are valuable tools for improving patient-doctor communication while strengthening their relation.
But not all dctors are so enthusiastic, worried that patients might misunderstand what they see in their doctors' notes, including complex descriptions of clinical evaluations and decisions.
Suzanne Salmon, associate chief of clinical geriatrics at Beth Israel Deaconess Medical Center in Boston, says giving patients more information is a good thing, but she worries how using common medical terminology might result: “words like 'growth-seeking behavior' drugs'; patients who wanted oxycodone and felt that it was not necessary, you have to be careful how you say that, because the patient may feel that it was necessary and may really resent the fact that they are thinking that it is a drug. looking person.”
The medical note has gone through many evolutions since the first known medical note in 1800 BC. Egypt, when surgical cases are transcribed on papyrus and used for teaching at a later time. In the 18th century, physicians wrote private journal entries. In the 20th century, notes were integrated into medical records, in an effort to systematize the collection of health information and data for billing.
The electronic format introduced in the 1980s, and now used in most US doctors' offices and hospitals, offered a potentially more efficient way to store and share medical data for use primarily by medical staff . Now, the medical note written by doctors after they have seen a patient is becoming a tool to communicate with the patient rather than just between healthcare providers and billing departments.
DesRoches says that she believes this new format "will help balance the imbalance of power between patients and physicians." Or, as the OpenNotes website puts it, he is “motivated by evidence that when healthcare professionals offer patients and their families quick access to clinical notes, the quality and safety of care improves.” .
“Your health record is your health record,” says Bettina Experton, a public health physician in California.
“It's also your doctor's record. But you have a right to access it,” adds Experton, founder of a doctor-led technology company that has been advocating for more than 20 years to give patients easier access to their health information, including clinical notes.
Stan Brady, a 65-year-old patient at the Cleveland Clinic with multiple chronic illnesses, says that reading his primary care and orthopedic doctors' clinical notes has helped clarify the doctor's instructions and remind him of medication regimens.
When DesRoches first heard about shared notes, he thought this would be useful only for patients with a high level of education and resources. But after years of research, his group found that patients traditionally unserved by the health care system are more likely to report benefit from reading their notes.
"Patients with lower levels of formal education, patients who have limited English proficiency, patients who self-identify as racial or ethnic minorities, are more likely to say that reading their doctors' notes helps them feel at ease. control of their care, helps them understand their medications, improves their trust in their provider,” she says.
But Salamon says she is concerned about how doctors can be edited knowing that patients can m
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